Demystifying Medicine One Week at a Time

NPR has a great blog on their website called “Shots” about current events in health care. Last week Scott Hensley, the main blogger there, posted about a recent article on treatment of prostate cancer from the Archives of Internal Medicine.

If you look at the article, you may notice a very small subheading above the article’s title. It reads “Less is More.”

Very telling.

The thrust of the article and the subsequent blog post is that men diagnosed with prostate cancer that have PSA values of less than 4.0 nanograms per milliliter of blood (“ng/mL”, the standard measurement) usually opt for treatment of their cancer, even though their cancer may not necessarily harm them.

What’s that, you say? How can cancer not harm someone?

This is an extremely vexing issue in the world of medicine, so it bears exploring.

Most importantly, it’s important to understand that “Cancer” is not one disease. This is perhaps the most commonly repeated media misconception, as when talking heads go to commercial break and say, “Coming up next: Scientists at Yada Yada U. claim that they have the cure for cancer. Is it true? Stay tuned to find out.”

Cancer is a process, in which the genetically-programmed regulation of normal cells goes haywire and leads to unfettered replication. It can occur in many different cell types, in almost any of your body’s organs. As such, there are numerous cellular and molecular targets of potential medicines, so a claim that one thing can cure [all] cancer is ludicrous on its face.

It so happens that on the spectrum of cancers, prostate cancer is the most commonly occurring one in men. That said, its fatality rate, the rate at which death is caused by the cancer, is very low.

How low?

Well, the five-year survival of diagnosed prostate cancer is one hundred percent. That means if you’re diagnosed with prostate cancer today, you’re essentially guaranteed to be around in five years. The ten-year survival is 91%. Not perfect, but not bad. I’d take those odds. [By the way, this is data I pulled from the American Cancer Society website.]

Contrast that to cancer of the pancreas. A much less common occurring cancer, but much more fatal: The five-year survival is 5.6%. [Source: National Cancer Institute.]

So what’s the point of all this?

I was taught an aphorism in medical school: “Most men die with prostate cancer, not because of it.” At autopsy, old men frequently had cancer in their prostates–but died from other, unrelated causes.

The point becomes think twice; think even four times about treating low grade prostate cancer. The treatments are invasive. The surgery usually leaves men with incontinence (leakage of urine) and impotence (inability to achieve erections). The problem is that the non-surgical option, radiation, causes the same harms at comparable rates.

Men are offered this bargain, and based on the article mentioned at the outset, it seems that they choose treatment over non-treatment (“watchful waiting”). For most of us, just hearing the word cancer is enough to make us terrified and want some kind of treatment, no matter how invasive. We’re a culture of doing something.

If you go over to the Shots blog linked at the top, you can read the comments below the post. Many are along the lines of “I’m grateful to have been diagnosed and treated early; my incontinence is mostly gone, or an inconvenience that I can live with, so this is article is a disservice to men everywhere, etc.”

I have no qualms with men having a choice about whether they want treatment or not. But those commenters suffer from what we call “treatment bias.” They want to justify their decision to undergo treatment, which is fine; I’m merely saying that treatment of ‘garden variety’ prostate cancer is neither mandatory, nor in every man’s best interest.

I will agree, however, that there exists an aggressive subtype of prostate cancer that metastasizes early and does have the power to harm and ultimately kill (cf. Zappa, Frank.)

And that’s what we need to figure out. Who (and how often) has this aggressive subtype that warrants more urgent treatment? Riches and prizes will certainly flow to those who solve this one.

But for the majority of men diagnosed with prostate cancer, watchful waiting (i.e. doing no harm) is a viable, underutilized option. This vexing issue is one of many examples of a Pandora’s box that our technologies (e.g. the PSA test) burden us with.

17 Comments

Nice post – it points to the merit of watchful waiting, which even in the 1980s and 1990s, when I learned and practiced oncology, was a treatment of choice for elderly men with low-grade prostate cancer.

The thing is, prostate cancer is not the same as breast cancer. And there’s been a lot of confusion in the press, especially in the past year, about the possibility of managing breast cancer with this approach. Particularly in younger women, breast cancer tends to be aggressive and is, most often, lethal when left untreated.

So it’s an important subject, but I hope readers don’t conflate the treatment recommendations regarding different kinds of cancer. Those differences matter a lot.

I was recently diagnosed with stage 1 Prostrate Cancer. I had 1 (maybe 2?) out of 12 sections come back positive. My PSA is 2.5, up from 1.5 a year ago. My Gleason score is 3/3. I am 54, and was recommended for a biopsy because my brother, who is 68, was diagnosed around 5 years ago and had his removed (robotic method) about 3 years ago.

I had a stent placed in my main coronary artery in 2006, when I was 50. My urologist has recommened surgery within the next 6 months or so. He says because of my age, I will probably have to have it removed eventually and better to do it now. Any thoughts?

Get a 2nd opinion. You won’t be able to find a urologist counselling against treating biopsy-proven cancer (too much liability potential there)—but seek a medical oncologist who’s done work on ‘watchful waiting.’ If you fit the paradigm there (sounds like your prostate Ca is low grade), waiting (with surveillance alone) could be an option for you.

Of course, if knowing you have prostate cancer is overwhelming, then treatment might make the most sense. In that case, there are of course other options beside surgery–different kinds of radiation therapy, and there’s now proton beam therapy. None of them are without side effects, unfortunately.

Read the “disclaimer” on this blog–the above is not meant to construe medical advice.

Actually my urologist recommended watchful waiting. I was diagnosed at age 70 with 2 partials out of 25. Gleason was 6. The next year there were 2 precancerous out of 18. I believe there was a large statistical study done at Rutgers which said treatment does not change the outcome. Now at age 73 I am not elderly. I skipped a biopsy last year but will have one this year. If the results are good I will stop having them. Intellectually I am sure I am doing the right thing. Emotionally it is a little harder.

That’s exactly it. For you, the Pandora’s Box has been opened. The emotion (stemming from the knowledge) is difficult to ignore. Had we had the USPSTF recommendation like we now have, perhaps you could’ve avoided suffering in this regard. Thanks for the comment.

So far my ‘active surveillance’ seems to be paying off. Had my 2nd biopsy in Sept and no cancer was detected. Know it’s still there but a clean biopsy is better than a positive one. My PSA has dropped to less than 1/2 my reading at time of my 1st biopsy. Taking numerous supplements and will soon start finasteride. Apparently have a slow growing tumor. Still yet, I would consider treatment if if it were reasonably innocuous….like HIFU (SonaBlate 500), an American technology but only available everywhere in the world but the USA. HIFU will probably be available in a few years but I’m already age 71.

I have a 75 year old retired medical doctor friend who is anti PSA. He’s never been tested. Am glad I was alerted to my condition but very hesitant to submit to invasive surgery.

Had a cyber-friend who learned too late that he had aggressive prostate cancer and he died within 2 years.

Over a decade ago I began cycling, seriously. I started to work out and I was 50-51. After five years of low PSA reading, the numbers began a climb that apparently worried the head urologist at the Veterans MC I visit. Two years ago, he biopsied because I’d reeached a 3.7. Three months of emotional North Sea sailing. The underlying question: does the cycling effect the PSA test? Now I see I hit 4.5, my free comes in 18%, and velocity a balmy 1.6. So I know were this guy is going (the dr.), however, it would be helpful to know definitively whether or not cycling plays havoc with the test. I’m at 2,824 miles for the year and average say 10+ every year. You see, when I go to the VA, they have two reactions: one, a cautionary urologist, and two, this guy’s so healthy! unlike the rest of our patients. Fundamentally, thet do not understand how aggressive my exercise is. My point is, stop the cycling does, does not effect the PSA. Design a study that statistically identifies the risk. Thanks.

I appreciate your comment. No doubt your tremendous physical exercise puts you in great shape with regard to cardiovascular health and other modern scourges like diabetes. Kudos to you! And to have started at such a relatively “advanced” age!

You’re right with respect to your comment–we just don’t know if or how cycling affects the gland and the PSA values.

But if you’ve had the biopsy, what did it show? I’m guessing that you had a low grade cancer, and have decided on watchful waiting–hence the anxiety about surveillance for you. You won’t get your current urologist to back off pushing treatment–he’s a hammer, and you’re the nail. You’ll have to stay strong to refuse ‘treatment.’

Could anyone comment regarding the potential spread of cancerous cells during a needle biopsy. I have read a number of articles regarding this “theory” (as my internist tells me) and the possibility is terrifying. I originally learned of “seeding the needle” track from my mother’s breast surgeon…it was chilling. In the course of one year my psa has decreased from 1.25 to .98 and my urologist said if it “continues to bounce around, we may need biopsy.” Thank you for any information.

Did you get an answer from anyone on this idea? I didn’t see any follow-up on the blog. I also want to know about the potential spread of cancerous cells during a needle biopsy for prostate cancer. The urologist just reccommeded this procedure to my partner and when I ask the dr. this question he was quick to pooh-pooh the idea and tell me I did too much reading! Needless to say we want nothing more to do with this dr. You mentioned you had read some articles on this theory. Could you comment further.
Thanks
Concerned Girlfriend

You doctors love to quote survival rates. Okay, the overall 10-year survival rate is 91%. The trouble is, that doesn’t account for all the men who are ill in year 10 and die in years 11, 12, etc. The 91% sounds like a good number. But would you take that number when driving your car? (Chance of surviving your trip: 91%)
So how about demanding, as a doctor, that the statistics be more realistic? I’d like to see this one: The percentage of regularly PSA-tested men without serious cancer effects when they die, vs. the percentage of non-tested men.

The question I have is what PSA number, approximately, is associated with death from prostate cancer? What PSA number is associated with major effects of prostate cancer?

If we know these numbers and we calculate the doubling rate of the PSA (easily done from a few tests) then we would know about how many years it would be before symptoms and death are expected to occur. When this is compared to your life expectancy it would be a lot easier to decide whether or not to seek treatment (with all the known side effects and quality of life changes).

Thank you for the interesting article on Watchful Waiting. Most physicians don’t like that term and prefer “active surveillance”. I was diagnosed with prostate cancer three years ago and have spent many hours researching the disease. I have chosen watchful waiting. My urologist and GP think that I’m a fool. My urologist urges me to get immediate treatment. He advocates “aggressive surveillance” as a temporary alternative to prostate removal.

My cancer should never have been found. At 60, my PSA has remained at about 1.0 +/-. I was being treated for prostatitis when my urologist felt something unusual during a DRE. A biopsy of 16 samples found the “nodule” (which has since gone away) to be benign. But a very small amount of Gleason 6 was found. That started the medical cascade.

Almost every physician that I meet urges me to have biopsies at least once every 18 months. If the first biopsy was a mistake, why submit to another? Prostate biopsies are not good for one’s health and I have refused to have another. If anything drives me to radical treatment (which will probably be unnecessary), it will be the grueling demands of active surveillance.